The Ethics Corner is a regular publication of the ABPP Ethics Committee, featuring clinical vignettes, ethical situations and dilemmas, and coverage of relevant ethical issues which arise in clinical and forensic settings. The ABPP Ethics Committee provides consultation services to ABPP specialists and constituents focused on responding to inquiries related to ethical standards, principles, and guidelines governing the practice of psychology. Contact them by submitting a Consultation Request Form and learn more on their website.
Terminating psychological health services is like the rest of life’s chapters; each ending is complex and unique; often requiring the psychologist to work through multiple ethical issues (O’Donohue and Cucciare, 2008). To develop a model of ethical problem solving for the termination phase, it is important to understand the common backstories to psychotherapy termination and the ethical challenges inherent in each of the following five termination scenarios:
1. Completed Termination Process
This is the most common process; both parties agree that the therapeutic goals have been accomplished and both parties feel there has been a successful termination process. Davis (2008) proposes the following six steps to the termination process but there is general agreement that a wide range of models could be appropriate. The key steps for Davis (2008) are a) setting a clear date for therapy to terminate, keeping in mind the goals of the client as well as the external restraints (e.g. time, finances, etc.), b) being mindful of a establishing a reasonable timeframe for the termination by setting the date a few weeks in advance, c) review progress and accomplishments, d) anticipate triggers for setbacks and challenges, d) create a relapse prevention plan, and e) say goodbye and give any additional resource referrals that are appropriate. When adhering to a model such as this, ethical mishaps are minimized.
2. Psychologist-Initiated Termination
Psychologist-Initiated Termination occurs when a) the psychologist is unable to successfully treat the client due to lack of progress, b) client hostility or other client behaviors non-conducive to treatment are directed towards the therapist, c) psychologist’s change of location or practice, d) lack of payment, e) the emergence of a problematic multiple relationship, and/or f) illness or death of the psychologist. The most common termination complaint of clients in this scenario are accusations of “abandonment”.
Most psychologists have had the experience of a client not making any progress and feel the client is better served elsewhere. Sometimes, a psychologist may feel uncomfortable with the client’s demands or lack of boundaries. Yet, they fear terminating the client for fear of being accused of “abandonment” (Younggren and Gottleib, 2008).
When a psychologist feels threatened or uncomfortable with a client, it is entirely appropriate to tell the client that they are not a good fit for one another and give the client the name of another clinic or provider. Depending on the nature and extent of the therapeutic relationship, the termination process may proceed as discussed above. But if the psychologist feels in danger, they can convey that referral information and summarize the work completed, in writing, and send it to the client.
To minimize the abandonment feelings when treatment is stopped due to psychologist illness or death, it is now normative and part of an ethical practice to leave a professional will that spells out how clients are to be transferred to other providers, who will have access to their records, how they will be notified and by whom, etc. Acknowledging that all too often, the psychologist may not know of realistic referral sources, without a wait list, who are able to see the client with their insurance and fee limitations, it is appropriate to supplement the names of referred providers with local self-help groups, and on-line communities that may help or know of other resources.
Clients may feel abandoned if the psychologist abruptly stops treatment without explanation or cause or if the psychologist does not respond to emails and phone calls in a timely manner. Also, if psychologists fail to provide coverage when they are unavailable or take leave for an extended period, a client may feel anxious and abandoned. Vybiral et al (2023) found the most negative emotions about treatment were associated with premature termination (whether therapist initiated or due to organizational restraints). It left them feeling vulnerable, pain, disappointment and abandonment. Hence, when the psychologist terminates therapy, it is important to document the reasons and the termination process that was followed.
Not infrequently, when clients feel abandoned by the psychologist they will try to reach out after termination with calls, letters, and/or texts. To avoid this issue, it is important to note in the initial discussions of termination, that you will not be available for these types of communications since they no longer are in treatment and the professional relationship has ceased.
3. Externally imposed Termination
Forced Termination is when institutional or other external forces (e.g. covid) may mandate termination. Here also, the likely ethical complaint would be one of “abandonment.” While the comments listed above apply here also, the psychologist facing institutional restrictions is also ethically bound to inform their organization about the inability to provide the needed services due to the organizational mandates. Additionally, the provider should document what goals were not achieved in the limited time available, as well as what goals were achieved. It is important to note that if the demands/mandates of an organization are in conflict with the Ethics Code, psychologists have three ethical obligations: a) they must clarify the nature of the conflict with the organization, b) they must make known their commitment to the Ethics Code, and c) they should take reasonable steps to find a solution to resolve the conflict consistent with the Ethical Standards of the Code (Standard 1.03).
If you must terminate due to external factors, you retain the ethical responsibility to act in the client’s best interest, by helping to secure viable referrals for similar/suitable services, providing handoff to other providers (with consent), and providing a final termination session or written summary, if feasible.
While there are clear guidelines around maintaining confidentiality, the ethics of trust in the therapeutic relationship should also be considered (Allen, 2022). It is important that when we enter into a therapeutic relationship, we do so with the ultimate regard for trust and do not intentionally violate that trust except in the most unavoidable situations. One should not, therefore, enter into a therapeutic relationship knowing that there may be externally imposed factors that may impact the longevity of the relationship, without attempting to clarify with the organization/institution first, and perhaps more importantly, disclosing to the client/patient, via a fully informed consent, any foreseeable barriers, including the likelihood of an early termination.
In general, we must be mindful when externally imposed terminations are upon us, that we are adhering to the spirit of the ethics code of doing no harm and acting in accordance with rules in line with these aspirations.
4. Client-Initiated Termination
The most common ethical complaints surrounding client-initiated termination is that the client feels they were “harmed” by the therapy. There are a number of ways a client may feel harmed by the therapeutic process or relationship, including a lack of fit between client’s needs and therapist’s skill set, power imbalances and tensions between control and safety enforcement, ethical infractions, cultural insensitivity, and real or perceived incompetence/lack of skill (Hardy et al, 2017).
One of the most effective ways to avoid accusations of harm in therapy is to use a feedback informed treatment model, where after each session, clients report whether they felt heard, respected, and helped. This allows the therapist to quickly address feelings of disappointment or anger and make self-efficacy a tool of empowerment for the client. Creating a treatment plan, early on, in collaboration with the client can help ensure you are clear regarding the goals and priority of treatment. Regularly sharing clinical conceptualizations, working diagnoses, and reflecting on progress and barriers can help to minimize potential ruptures and prompt for opportunities to repair. Regular feedback during therapy should be the norm, rather than the exception (Hardy et al., 2017).
In sum, to mitigate the experience of harm during psychotherapy, clients should be involved in the decision-making process, including being explicitly clear about the goals and objectives of sessions and progress made (Hardy et al., 2017).
5. The Non-Terminators
Today, there is an increasing group of clients who see therapy as part of their wellness routine. They don’t ever plan to terminate.Still, it is ethically important to assess if termination is appropriate on a periodic basis, to avoid reinforcing dependency needs. If both therapist and client feel that the client benefits from their discussions, it is entirely ethical to keep seeing them. However, for record keeping and insurance purposes, clients must continue to receive appropriate diagnostic codes, including withholding a diagnosis if none meet DSM criteria.
Periodically reviewing treatment plans together and clarifying goals using objective measurable data can be particularly helpful in ensuring the therapy is, in fact, remaining therapeutic.
For long-term clients, the frequency of termination discussions depends on multiple factors such as the goals of the therapy, the length of ongoing treatment, the strength of the therapeutic alliance, the dependence of the client, etc. There are three questions psychologists must explore in these cases: a) Has the work achieved all the client’s goals that they can reasonably expect to achieve? b) Is it reasonable to expect that maintenance of the gains is significantly improved by continuing therapy or significantly threatened by termination? c) Is any harm or exploitation (including financial exploitation) involved in continuing treatment?
A long-term client is very often an easy, enjoyable client, even when doing difficult work together. Thus, psychologists need to be introspective and non-defensive and question whether the treatment has more benefits for them than for the client (Davis and Younggren, 2009).
What ethical principles and guidelines address termination?
Although these five categories each present their own termination issues, all of them are guided by the following ethical principles and guidelines (Davis and Younggren, 2009):
Each of the APA Ethical Principles helps us understand our obligations during the termination process but Principle A and C are most critical. Principle A, Beneficence and Nonmaleficence directs psychologists to “do no harm” and this includes the monetary harm incurred by having unneeded services, potentially harmful multiple relationships, inappropriate dependency on the therapist or vice versa. Principle C, Integrity, advises to “avoid unwise or unclear commitments” which could include promising continuing services without discussing insurance and personal limitations, lack of progress, misfit in personalities or other factors.
Guideline 10.10 speaks directly to the ethical mandates during termination. It states:
10.10 Terminating Therapy
(a) Psychologists terminate therapy when it becomes reasonably clear that the client/patient no longer needs the service, is not likely to benefit, or is being harmed by continued service.
(b) Psychologists may terminate therapy when threatened or otherwise endangered by the client/patient or another person with whom the client/patient has a relationship.
(c) Except where precluded by the actions of clients/patients or third-party payors, prior to termination psychologists provide pretermination counseling and suggest alternative service providers as appropriate (APA, 2017).
How best to insure a successful termination process?
The termination process always begins with the informed consent and the treatment contract that precedes the work of therapy.
The termination process should be discussed in the informed consent documents and discussions, so the client understands the termination process that occurs in successful psychotherapy as well as the other types of termination (see above).
The clearer the treatment goals, the clearer it will be when a “successful termination” will occur. In your informed consent agreement, have a section describing when the psychologist is free to terminate treatment with the client, citing factors such as: a) inability of the therapist to competently provide the needed services, b) multiple relationships that could potentially interfere with treatment, c) change in practice load, location or hours, d) inability of the patient to pay for services, e) patient coming to sessions on drugs and/or unable to participate in the required manner, and f) the psychologist not feeling safe during the sessions. Also, it is important to note that the termination process can take one session or multiple sessions, depending on many different factors (Feindler, 2006).
Termination is an ongoing discussion, linked with regular assessment of progress towards treatment goals. Many therapists have found that formalizing the termination process provides important closure and ensures that clients know how to reach out for help at a later date, if needed.
To foster closure, some therapists create “goodbye notes”, especially in the case of successful terminations. The letter summarizes gains achieved as well as the pleasure of working together and the psychologist’s availability in the future, if the need arises.
In summary, ethical practice includes discussing termination as part of the treatment contract, monitoring that clients feel you are acting in their best interest throughout treatment and routinely having termination sessions. In the termination session, the psychotherapy experience is processed, gains are acknowledged and plans to avoid relapse and to strengthen resiliency are reviewed. Understanding the range of termination experiences heightens our understanding of the multiple issues surrounding the end of a rare and most often, very important relationship in our lives and our client’s lives.
Checklist to Help Assure Competent, Ethical Termination:
- Did I go over the informed consent agreement and the termination process in detail and answer all the client’s questions?
- Was the termination process planned?
- Was the termination process successful in consolidating gains and providing closure for the client?
- If initiated by one of the parties, was the client given appropriate notice of termination and appropriate guidance about seeking further help?
References
Allen, J. G. (2022). Trusting in psychotherapy. American Psychiatric Association Publishing.
American Psychological Association. (2017). Ethical principles of psychologists and code of conduct (2002, amended effective June 1, 2010, and January 1, 2017). https://www.apa.org/ethics/code/
Davis, D. D. (2008). Terminating therapy: A professional guide for ending on a positive note. Psychotherapy: Theory, Research, Practice, Training, 45(4), 442–450. https://doi.org/10.1037/a0014101
Davis, D. D., & Younggren, J. N. (2009). Ethical competence in psychotherapy termination. Professional Psychology: Research and Practice, 40(6), 572–578. https://doi.org/10.1037/a0017699
Feindler, E. L. (2006). Termination issues. In F. W. Kaslow (Ed.), Comprehensive handbook of psychotherapy: Vol. 4. Integrative/eclectic (pp. 443–464). John Wiley & Sons.
Hardy, G. E., Bishop-Edwards, L., Chambers, E., Connell, J., Dent-Brown, K., Kothari, G., O’Hara, R., Parry, G. D. (2017). Risk factors for negative experiences during psychotherapy. Psychotherapy Research, 29(3), 403–414. https://doi.org/10.1080/10503307.2017.1393575
O’Donohue, W. T., & Cucciare, M. A. (Eds.). (2008). Terminating psychotherapy: A clinician’s guide (1st ed.). Routledge.
Vybíral, Z., Ogles, B. M., Řiháček, T., Urbancová, B., & Gocieková, V. (2023). Negative experiences in psychotherapy from clients’ perspective: A qualitative meta-analysis. Psychotherapy Research, 34(3), 279–292. https://doi.org/10.1080/10503307.2023.2226813
Younggren, J. N., & Gottlieb, M. C. (2008). Termination and abandonment: History, risk, and risk management. Professional Psychology: Research and Practice, 39(5), 498–504. https://doi.org/10.1037/0735-7028.39.5.498
Linda Berg-Cross, PhD, ABPP, CBSM
Board Certified in Clinical Psychology
Correspondence: lindabergcross@gmail.com
Hilary Sherry, PhD, ABPP
Board Certified in Clinical Psychology
Correspondence: hsherry@menninger.edu